Valeria Fiaschetti

Breast Reconstruction with Autologous Fat Graft Mixed with Platelet-Rich Plasma

Background. The purpose of this study was to review the authors’ experience of fat grafting, evaluating the effects related to the use of fat grafting with platelet-rich plasma (PRP) in the improvement of fat volume in breast reconstruction and comparing the results with a control group (only centrifuged fat grafting). Methods. A total of 50 patients aged between 19 and 60 years affected by breast soft-tissue defects were analyzed at the Plastic and Reconstructive Department of the University of Tor Vergata. They were treated with fat grafting + PRP. The control group (50 patients with breast soft-tissue defects) were treated with centrifuged fat grafting injection according to Coleman’s procedure. Results. The patients treated with PRP added to the autologous fat grafts showed a 69% maintenance of the contour restoring and of 3-dimensional volume after 1 year, whereas the patients of the control group treated with centrifuged fat grafting showed a 39% maintenance. Conclusion. PRP mixed with fat grafting leads to an improvement in maintaining breast volume in patients affected by breast soft-tissue defects.

MR imaging-guided 10-gauge vacuum-assisted breast biopsy: histological characterisation

PurposeThe aim of this study was to evaluate a handheld vacuum-assisted device for magnetic resonance imaging (MRI)-guided breast biopsy.Materials and methodsIn 47 patients, a total of 47 suspicious breast lesions (mean maximum diameter 9 mm) seen with MRI (no suspicious changes on breast ultrasound or mammography) were sampled using a 10-gauge vacuum-assisted breast biopsy (VAB) device under MRI guidance. Histology of biopsy specimens was compared with final histology after surgery or with follow-up in benign lesions.ResultsTechnical success was achieved in all biopsies. Histological results from VAB revealed malignancy in 15 lesions (32%), atypical ductal hyperplasia in four lesions (8%) and benign findings in 28 lesions (60%). One of four lesions with atypical ductal hyperplasia was upgraded to ductal carcinoma in situ after surgery. One of seven lesions showing ductal carcinoma was upgraded to invasive carcinoma after surgery. Two lesions diagnosed as infiltrating carcinoma by VAB were not validated at excisional biopsy due to complete removal of the lesion during the procedure. During the follow-up (mean 18 months) of histologically benign lesions, we observed no cases of breast cancer development. Because of morphological changes on follow-up MRI scans, two lesions underwent surgical excision, which confirmed their benign nature. Besides minor complications (massive bleeding, n=1) requiring no further therapeutic intervention, no complications occurred.ConclusionsMRI-guided biopsy of breast lesions using a handheld vacuum-assisted device is a safe and effective method for the workup of suspicious lesions seen on breast MRI alone.RiassuntoObiettivoValutare l’accuratezza diagnostica dei prelievi con sistema portatile ad aspirazione retroazionata (VAB) 10 gauge sotto-guida RM nella caratterizzazione delle lesioni mammarie visibili unicamente alla RM.Materiali e metodi47 lesioni (diametro massimo 9 mm) visibili unicamente all’esame RM, sono state caratterizzate usando un sistema portatile ad aspirazione retroazionata (VAB) con ago da 10 Gauge, sotto guida RM. L’istologia delle biopsie VAB è stata confrontata con l’istologia definitiva dopo l’escissione chirurgica o con i reperti di follow-up.RisultatiIl successo tecnico è stato ottenuto in tutti i casi. I risultati istologici della biopsia VAB hanno mostrato 15 lesioni maligne (32%), 4 lesioni classificabili come iperplasia duttale atipica (ADH) (8%), e 28 lesioni come benigne (60%). Alla istologia definitiva una delle quattro lesioni classificate come ADH è stata riclassificata come carcinoma duttale in situ (DCIS), mentre una delle lesioni classificate come DCIS è stata riclassificata come carcinoma invasivo. Due lesioni diagnosticate al VAB come carcinoma infiltrante non sono state riscontrate alla istologia definitiva, probabilmente a causa della totale rimozione durante la procedura VAB. Il follow-up delle lesioni benigne ha confermato la benignità delle lesioni. Due lesioni benigne che all’Imaging RM hanno mostrato una modificazione della morfologia, sono andate incontro ad intervento chirurgico che ha confermato la benignità della lesione. Ad eccezione di un massivo sanguinamento in 1 caso, non si sono osservate complicanze.ConclusioniI prelievi VAB sotto-guida RM sono una mammetodica sicura ed efficace per la caratterizzazione delle lesioni mammarie visibili unicamente all’RM.

Gallbladder Agenesis and Cystic Duct Absence in an Adult Patient Diagnosed by Magnetic Resonance Cholangiography: Report of a Case and Review of the Literature

Gallbladder agenesis (GA) is a rare congenital anomaly of the biliary system often associated with other congenital abnormalities. Patients become symptomatic in 23% of cases. GA is often misinterpreted as other diseases, therefore, leading to unnecessary surgery. We report a case of congenital GA associated to cystic duct absence and a biliary tract abnormality diagnosed by Magnetic Resonance with Cholangiopancreatography.

Deeply infiltrating endometriosis: evaluation of retro-cervical space on MRI after vaginal opacification.

OBJECTIVES To prospectively investigate diagnostic value and tolerability of MRI after intra-vaginal gel opacification for diagnosis and preoperative assessment of deeply infiltrating endometriosis. METHODS Sixty-three women with clinical suspicion of deeply infiltrating endometriosis were previously examined with trans-vaginal ultrasonography and then with MRI pre and post administration of vaginal gel. We evaluated the tolerability of this procedure with a scoring scale from 0 to 3. We also assessed with a score from 1 to 4 the visibility of four regions: Douglas-pouch, utero-sacral-ligaments, posterior-vaginal-fornix and recto-vaginal-septum. All patients underwent laparoscopic surgery after MRI. RESULTS Five patients considered procedure intolerable. Visibility of utero-sacral-ligaments and posterior-vaginal-fornix showed to be increased with gel (p<0.001). In 57 out of 80 patients the MRI has allowed us to diagnose deeply infiltrating endometriosis. Overall, the percentages of MRI-sensitivity, specificity, positive predictive value and negative predictive value were respectively 67.8%, 95.3%, 89.4 and 83.5% without gel, and 90.8%, 94.6%, 90.8% and 94.6% with gel; trans-vaginal ultrasonography sensitivity, specificity, positive predictive value and negative predictive value were 57.5%, 96.6%, 90.9% and 79.5%. In evaluation of utero-sacral-ligaments trans-vaginal ultrasonography, MRI without gel and with gel sensitivity was respectively 61.9%, 47.6% and 81%; for recto-vaginal-septum these values were 12.5%, 68.7% and 93.7%; for pouch of Douglas 82%, 87% and 97.4%; finally for posterior-vaginal-fornix 27.3%, 36.4% and 81.8%. CONCLUSIONS MRI with gel opacification of vagina should be recommended for suspicion of deep infiltrating endometriosis, in particular for the added value in evaluation of recto-vaginal septum, utero-sacral ligaments and posterior vaginal fornix.

Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal

BackgroundSeveral techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. We conducted a prospective study to assess type of presentation, treatment strategy and outcome over a 5-year period.MethodsBetween 1st January 2005 and 31st March 2011 247 patients presenting with anal fistulas were treated at the University Hospital Tor Vergata and were included in the present prospective study. Mean age was 47 years (range 16-76 years); minimum follow-up period was 6 months (mean 40, range 6-74 months).Patients were treated using 4 operative approaches: fistulotomy, fistulectomy, seton placement and rectal advancement flap. Data analyzed included: age, gender, type of fistula, operative intervention, healing rate, postoperative complications, reinterventions and recurrence.ResultsEtiologies of fistulas were cryptoglandular (n = 218), Crohns disease (n = 26) and Ulcerative Colitis (n = 3). Fistulae were classified as simple -intersphincteric 57 (23%), low transphincteric 28 (11%) and complex -high transphicteric 122 (49%), suprasphincteric 2 (0.8%), extrasphinteric 2 (0.8%), recto-vaginal 7 (2.8%) Crohn 26 (10%) and UC 3 (1.2%).The most common surgical procedure was the placement of seton (62%), usually applied in case of complex fistulae and Crohns patients.Eighty-five patients (34%) underwent fistulotomy, mainly for intersphincteric and mid/low transphincteric tracts. Crohns patients were submitted to placement of one or more loose setons.The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%). Three cases of major incontinence (1.3%) were detected during the follow-up period; Furthermore, three patients complained minor incontinence that was successfully treated by biofeedback and permacol injection into the internal anal sphincter.ConclusionsThis prospective audit demonstrates an high proportion of complex anal fistulae treated by seton placement that was the most common surgical technique adopted to treat our patients as a first line. Nevertheless, a good outcome was achieved in the majority of patients with a limited rate of faecal incontinence (6/247 = 2.4%). New technologies provide promising alternatives to traditional methods of management particularly in case of complex fistulas. There is, however, a real need for high-quality randomized control trials to evaluate the different surgical and non surgical treatment options.

Mayer-Rokitansky-Kuster-Hauser Syndrome diagnosed by Magnetic Resonance Imaging. Role of Imaging to identify and evaluate the uncommon variation in development of the female genital tract

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a spectrum of Müllerian duct anomalies characterized by congenital aplasia of the uterus and of the upper part (2/3) of the vagina, in young women presenting otherwise with normal endocrine status. The ovaries and fallopian tubes are present. It is one of the most common causes of primary amenorrhea and affects at least 1 out of 4500 women. Its penetrance varies, as does the involvement of other organ systems and itcan be isolated (type I) or associated with other malformations (type II). The MRKH syndrome usually remains undetected until the patient presents with primary amenorrhea despite normal development of secondary sexual characteristics, so imaging evaluation can demonstrate in one setting, non invasively, the anomalies in development of genital tract. We report a case of MRKH syndrome in a 16-year-old woman who presented with primary amenorrhea, stressing the role and benefit of imaging in the differential diagnosis.

Adult Intra-Thoracic Kidney: A Case Report of Bochdalek Hernia

Introduction. Bochdalek hernia is a congenital posterior lateral diaphragmatic defect that allows abdominal viscera to herniate into the thorax. Intrathoracic kidney is a very rare finding representing less than 5% of all renal ectopias with the least frequency of all renal ectopias. Case Presentation. We report a case of a 62-year-old man who had a left thoracic kidney associated with left Bochdalek hernia. Abdominal X-ray and chest X-ray revealed dilated loops of the colon above left hemidiaphragm. Abdominal ultrasound (US) showed the right kidney with many fluid and esophytic cysts; left kidney was unfeasible to study because of the impossibility to find it. Computed Tomography (CT) basal scan demonstrated a left-sided Bochdalek hernia with dilatated colon loops and the left kidney within the pleural space. Magnetic Resonance (MR) confirmed a defect in left hemidiaphragm with herniation of left kidney, omento, spleen and colon flexure, and intrarotation with posterior hilum on sagittal plane. Conclusion. The association of a Bochdalek hernia and an intrathoracic renal ectopia is very rare, that pose many diagnostic and management dilemmas for clinicians. Our patient has been visualized by CT and MR imaging. A high index of suspicion can result in early diagnosis and prompt intervention with reduced morbidity and mortality.

Hemoperitoneum from Corpus Luteal Cyst Rupture: A Practical Approach in Emergency Room

Corpus luteum cyst rupture with consequent hemoperitoneum is a common disorder in women in their reproductive age. This condition should be promptly recognized and treated because a delayed diagnosis may significantly reduce womens fertility and intra-abdominal bleeding may be life-threatening. Many imaging modalities play a key role in the diagnosis of acute pelvic pain from gynecological causes. Ultrasound study (USS) is usually the first imaging technique for initial evaluation. USS is used to confirm or to exclude the presence of intraperitoneal fluid but it has some limitations in the identification of the bleeding source. Contrast-enhanced computed tomography (CT) is the imaging modality which could be used in the acute setting in order to recognize gynecological emergencies and to establish a correct management. Magnetic resonance imaging (MRI) nowadays is the most useful technique for studying the pelvis but its low availability and the long acquisition time of the images limit its usefulness in characterization of acute gynecological complications. We report a case of a young patient with hemoperitoneum from hemorrhagic corpus luteum correctly identified by transabdominal USS and contrast-enhanced CT.

Mixed Hepatoblastoma in a Young Male Adult: A Case Report and Literature Review

Hepatoblastoma (HB) is a rare malignant tumour of the liver and usually occurs in the first three years of life. Most of these tumours arise in the embryo; hence it seems to be unusual that hepatoblastoma occurs in adults and is an exceptional cause of primary malignant liver tumour in adult patients. The diagnosis is often overlooked, and patients might be diagnosed at late stages of the disease at risk of increased mortality. In this paper we report a case of a 30-year-old man with mixed hepatoblastoma and abdominal pain, hepatomegaly and fever. The patient under went noninvasive diagnostic methods: duplex scanning, Computed Tomography (CT), and Magnetic Resonance imaging (MRI). In our experience, despite the important role of histological sample provided by biopsy in defining the diagnosis, very important was the role of MRI, more than ultrasonography and enhanced CT. The MRI detects tumor features as size, margins, and ratio with neighboring organs in order to get the best surgical approach.

Static and dynamic evaluation of pelvic floor disorders with an open low-field tilting magnet

AIM To assess the feasibility of magnetic resonance defaecography (MRD) in pelvic floor disorders using an open tilting magnet with a 0.25 T static field and to compare the results obtained from the same patient both in supine and orthostatic positions. MATERIALS AND METHODS From May 2010 to November 2011, 49 symptomatic female subjects (mean age 43.5 years) were enrolled. All the patients underwent MRD in the supine and orthostatic positions using three-dimensional (3D) hybrid contrast-enhanced (HYCE) sequences and dynamic gradient echo (GE) T1-weighted sequences. All the patients underwent conventional defaecography (CD) to correlate both results. Two radiologists evaluated the examinations; inter and intra-observer concordance was measured. The results obtained in the two positions were compared between them and with CD. RESULTS The comparison between CD and MRD found statistically significant differences in the evaluation of anterior and posterior rectocoele during defaecation in both positions and of rectal prolapse under the pubo-coccygeal line (PCL) during evacuation, only in the supine position (versus MRD orthostatic: rectal prolapse p < 0.0001; anterior rectocoele p < 0.001; posterior rectocoele p = 0.008; versus CD: rectal prolapse p < 0.0001; anterior rectocoele p < 0.001; posterior rectocoele p = 0.01). The value of intra-observer intra-class correlation coefficient (ICC) ranged from good to excellent; the interobserver ICC from moderate to excellent. CONCLUSION MRD is feasible with an open low-field tilting magnet, and it is more accurate in the orthostatic position than in the supine position to evaluate pelvic floor disorders.